Northern England Strategic Clinical Network Conference 15 th May 2015 Five Year Forward View and Maternity

Five Year Forward View Maternity Services CCG perspective – Multiple competing demands on time / resource – Maternity services are “OK” – No radical innovations and / or new treatments – No clear direction from DH

Five year forward view Maternity services To ensure maternity services develop in a safe, responsive and efficient manner, in addition to other actions underway – including increasing midwife numbers - we will: – Commission a review of future models for maternity units, to report by next summer, which will make recommendations on how best to sustain and develop maternity units across the NHS. – Ensure that tariff-based NHS funding supports the choices women make, rather than constraining them. – As a result, make it easier for groups of midwives to set up their own NHS- funded midwifery services.

Birthplace study Primary outcome (ie perinatal mortality / morbidity) Planned place of birth No. of eventsIncidence / 1000 (95% CI) Odds ratio (adjusted) Obstetric unit48/ (2.2 to 4.2)1.00 Home62/ (3.0 to 5.3)1.59 (1.01 to 2.52) Freestanding MLU35/ (2.3 to 4.6)1.22 (0.76 to 1.96) Alongside MLU54/ (2.4 to 4.9)1.26 (0.80 to 1.99) Birthplace Collaborative Group BMJ d7400

Birthplace study Primary outcome (ie perinatal mortality / morbidity) Birthplace Collaborative Group BMJ d7400

Increasing MLU births Challenges Current actual / planned reductions in freestanding MLUs in the NE Actual (rather than stated) choice of pregnant women Increasing acuity of pregnant population Increasing number of indications for IOL Societal changes in attitude to elective CS

Saving Babies’ Lives Reducing SBs and early NND SB rate in UK one of the highest in Europe In UK, about 33% difference between different regions Affects 1 in babies About 4000 SBs every year in the UK SB reduction mandate from government to NHS England

State of the World’s Mothers 2014 Lifetime risk of maternal death Save the Children

The Morecambe Bay Report “Our findings are stark, and catalogue a series of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the Trust. The nature of these problems is serious and shocking, and it is important for the lessons of these events to be learnt and acted upon, not only to improve the safety of maternity services, but also to reduce risk elsewhere in NHS systems.” Dr Bill Kirkup CBE

Morecambe Bay Investigation A “dysfunctional maternity unit” 1.Clinical competence of some staff fell significantly below the standard required for a safe, effective service 2.The working relationships between different groups of staff were extremely poor 3.Midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care. 4.Advice to mothers that it was appropriate to consider delivery at FGH was significantly compromised by a failure to assess the risks properly. 5.The response from unit clinicians to serious incidents was grossly deficient. Dr Bill Kirkup CBE

Anoxic neonatal death Time of birth (Scotland 1985 – 2004) Pasupathy (n=1,039,560)

State of Maternity Services 2013 Age profile of midwives

CfWI O&G stocktake – January 2015 Principal projections for O&G CCT holders CfWI system dynamics model of the O&G CCT holder workforce for England

Five Year Forward View Maternity Services Much to be celebrated about maternity care Significant current concerns about quality of care Recognition from DH of the need for change Major embedded, structural difficulties Collaborative working with CCGs essential

Five Year Forward View Maternity Services Birth is the most common reason for hospital admission Births up about 25% in last decade, and at highest for 40yrs Low risk mothers giving birth in midwife-led units or at home have fewer interventions, with same outcomes 80% of women live within an MLU Research by WI and NCT suggests over 85% of women give birth in a obstetric unit despite only 25% wanting to do so

National NHS patient survey: 2013 Women’s experiences of maternity services PrimipsMultipsSignificant change Did midwives provide relevant info about feeding your baby - yes, definitely55%67%↑ - yes, to some extent34%25%↓ - no11%8%↓ Did midwives give you consistent advice about feeding your baby - yes, definitely47%61%↑ - yes, to some extent29%24%↓ - no23%12%↓ - I did not receive any advice2% ↑

Birthplace study Primary outcome (ie perinatal mortality / morbidity) Planned place of birth No. of events*Incidence / 1000 (95% CI) Odds ratio (adjusted) Obstetric unit28/ (2.4 to 5.1)1.00 Home36/ (6.6 to 13.7)2.80 (1.59 to 4.92) Freestanding MLU22/ (2.8 to 7.4)1.40 (0.74 to 2.65) Alongside MLU35/ (2.7 to 7.0)1.38 (0.75 to 2.52) * Women without complicating conditions at start of labour Birthplace Collaborative Group BMJ d7400